Case report Korean J Pediatr 2014;57(3):153-156 http://dx.doi.org/10.3345/kjp.2014.57.3.153 pISSN 1738-1061•eISSN 2092-7258
Korean J Pediatr
Toxic epidermal necrolysis induced by lamotrigine treatment in a child Youngsuk Yi, MD, Jeong Ho Lee, MD, Eun Sook Suh, MD Department of Pediatrics, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
Toxic epidermal necrolysis is an unpredictable and severe adverse drug reaction. In toxic epidermal ne crolysis, epidermal damage appears to result from keratinocyte apoptosis. This condition is triggered by many factors, principally drugs such as antiepileptic medications, antibiotics (particularly sulfonamide), nonsteroidal anti-inflammatory drugs, allopurinol, and nevirapine. Lamotrigine has been reported potentially cause serious cutaneous reactions, and concomitant use of valproic acid with lamotrigine significantly increases this risk. We describe a case of an 11-year-old girl with tic and major depressive disorders who developed toxic epidermal necrolysis after treatment with lamotrigine, and who was diagnosed both clinically and pathologically. Children are more susceptible to lamotrigine-induced rash than adults, and risk of serious rash can be lessened by strict adherence to dosing guidelines. Unfor tunately, in our case, the patient was administered a higher dose than the required regimen. Therefore, clinicians should strictly adhere to the dose regimen when using lamotrigine, especially in children.
Corresponding author: Eun Sook Suh, MD Department of Pediatrics, Soonchunhyang Univer sity Hospital, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-gu, Seoul 140-743, Korea Tel: +82-2-709-9158 Fax: +82-2-795-3687 E-mail: [email protected] Received: 11 January, 2013 Revised: 8 April, 2013 Accepted: 19 July, 2013
Key words: Toxic epidermal necrolysis, Adverse drug reaction, Lamotrigine, Antiepileptic drug
Introduction Toxic epidermal necrolysis (TEN) is a life-threatening cutaneous reaction associated with 30% mortality1). Inappropriate immune activation is triggered in response to certain drugs or their metabolites. Numerous medications have been implicated as causes of TEN, the most frequently associated drugs include aromatic anticonvulsants, sulfonamide antibiotics, allopurinol, oxicam nonsteroidal anti-inflammatory drugs, and nevirapine2). Diagnosis relies mainly on clinical signs together with the histological analysis of a skin biopsy showing typical full-thickness epidermal necrolysis due to extensive keratinocyte apoptosis3). Lamotrigine is a relatively new anticonvulsant. It is used for different types of epilepsy and also effective in treating and preventing bipolar depression. The risk of TEN with combination lamotrigine and valproate is greater than with monotherapy4). Children are more susceptible to lamotrigine-rash than are adults5). TEN is rare disease with incidence of approximately 1.9 cases per million inhabitants annually based on all cases reported to the Food and Drug Administration (FDA) adverse effect reporting system databases in the USA6), and is also rare disease in Korea7). We report a case of TEN in a child that occurred after addition of lamotrigine to the valproic acid treatment, and who was diagnosed clinically and pathologically.
Case report An 11-year-old girl was hospitalized for erythematous maculopapular rash with an
Copyright © 2014 by The Korean Pediatric Society This is an open-access article distributed under the terms of the Creative Commons Attribution NonCommercial License (http://creativecommons.org/ licenses/by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
http://dx.doi.org/10.3345/kjp.2014.57.3.153
153
Yi Y, et al. • Lamotrigine induced toxic epidermal necrolysis
Fig. 1. Diffuse and confluent erythema that covered ≥90% of the total body surface area of the patient on day 1 of hospitalization.
itching sensation over the entire body with fever, conjunctival in jection, eye wax, and oral ulceration. The patient had experience tic disorder since the age of 8 years, and had been diagnosed with major depressive disorder about 7 months previously. The patient was initially treated with fluoxetin, valproate, risperidone, and aripiprazole in psychiatric clinic. However, because of inadequate control, lamotrigine (25 mg/day) was added to the regimen about 3 weeks before hospitalization. After 2 weeks use of lamotrigine, the patient developed an erythematous rash, starting from the face and gradually spreading over the whole body. The patient transfered to Soonchunhyang University Hospital with a diffuse, confluent erythema, which covered over 90% of the total body surface area, conjunctival injection, eye wax, vesicle, and clot on lips and oral ulceration (Fig. 1). The patient also had a fever and skin tenderness, and could not eat properly because of oral pain. During the hospitalization, the skin lesion progressed to a purpuric rash with bullae (Fig. 2). Hemorrhagic crust on the lip was aggravated and Nikolsky’s sign was positive. There was no history of food or drug allergy. Laboratory examination revealed normal complete blood count and serum biochemistry, normal erythrocyte sedimentation rate, and elevated C-reactive protein (7.56 mg/dL). Urinalysis showed pyuria (leukocyte 3+), but urine culture was negative. Chest x-ray was normal. Skin biopsy revealed necrotic keratinocyte in the epidermis with spongiosis and exocytosis, and lymphohistiocytic infiltration in the upper dermis, which suggested TEN (Fig. 3). Consultations with a dermatologist, a plastic surgeon, a psy chiatrist, an ophthalmologist and an otorhinolaryngologist were conducted. We stopped all the psychiatric medications and started intravenous (IV) antibiotics, suspecting secondary infection, in travenous immunoglobulin (IVIG;1.5 gm/kg/day for 3 days)8), and other conservative management including IV hydration, aseptic dressing, topical ointment, nasal irrigation using normal saline, oral humidification, and eye drops. After a week of hospitalization, the skin lesion showed desquamation and was improving (Fig. 4). The tic symptom recurred 2 weeks after we stopped the psychiatric medication, so we used aripiprazole. After
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http://dx.doi.org/10.3345/kjp.2014.57.3.153
Fig. 2. Generalized dark purpuric erythema with bullae on the trunk.
19 days of hospitalization, the lesion became much improved and the patient was discharged.
Discussion TEN is an unpredictable and severe adverse drug reaction. Although several theories exist, the innate immune system is now favored as a significant contributor to the initiation and propagation of this devastating reaction9). TEN is heralded by the abrupt onset of fever; systemic toxicity; a generalized, dusky, and erythematous rash; bullae; separation of large sheets of epidermis from the dermis; purulent conjunctivitis;
Korean J Pediatr 2014;57(3):153-156
Fig. 3. Histology of the skin biopsy specimen of the patient, showing necrosis of epidermal keratinocytes and lymphocytic infiltration in the upper dermis (H&E, ×200).
Fig. 4. The skin lesion, showing desquamation and improvement.
and mucositis of the mouth and genital area2). In our case, the patient had oral, nasal mucosa and conjunctival involvements along with fever. Complete death of the epidermis leads to sloughing similar to that seen in large burns. TEN includes denudation of >30% of the total body surface area. Stevens-Johnson syndrome (SJS) affects
Korean J Pediatr
Toxic epidermal necrolysis induced by lamotrigine treatment in a child Youngsuk Yi, MD, Jeong Ho Lee, MD, Eun Sook Suh, MD Department of Pediatrics, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
Toxic epidermal necrolysis is an unpredictable and severe adverse drug reaction. In toxic epidermal ne crolysis, epidermal damage appears to result from keratinocyte apoptosis. This condition is triggered by many factors, principally drugs such as antiepileptic medications, antibiotics (particularly sulfonamide), nonsteroidal anti-inflammatory drugs, allopurinol, and nevirapine. Lamotrigine has been reported potentially cause serious cutaneous reactions, and concomitant use of valproic acid with lamotrigine significantly increases this risk. We describe a case of an 11-year-old girl with tic and major depressive disorders who developed toxic epidermal necrolysis after treatment with lamotrigine, and who was diagnosed both clinically and pathologically. Children are more susceptible to lamotrigine-induced rash than adults, and risk of serious rash can be lessened by strict adherence to dosing guidelines. Unfor tunately, in our case, the patient was administered a higher dose than the required regimen. Therefore, clinicians should strictly adhere to the dose regimen when using lamotrigine, especially in children.
Corresponding author: Eun Sook Suh, MD Department of Pediatrics, Soonchunhyang Univer sity Hospital, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-gu, Seoul 140-743, Korea Tel: +82-2-709-9158 Fax: +82-2-795-3687 E-mail: [email protected] Received: 11 January, 2013 Revised: 8 April, 2013 Accepted: 19 July, 2013
Key words: Toxic epidermal necrolysis, Adverse drug reaction, Lamotrigine, Antiepileptic drug
Introduction Toxic epidermal necrolysis (TEN) is a life-threatening cutaneous reaction associated with 30% mortality1). Inappropriate immune activation is triggered in response to certain drugs or their metabolites. Numerous medications have been implicated as causes of TEN, the most frequently associated drugs include aromatic anticonvulsants, sulfonamide antibiotics, allopurinol, oxicam nonsteroidal anti-inflammatory drugs, and nevirapine2). Diagnosis relies mainly on clinical signs together with the histological analysis of a skin biopsy showing typical full-thickness epidermal necrolysis due to extensive keratinocyte apoptosis3). Lamotrigine is a relatively new anticonvulsant. It is used for different types of epilepsy and also effective in treating and preventing bipolar depression. The risk of TEN with combination lamotrigine and valproate is greater than with monotherapy4). Children are more susceptible to lamotrigine-rash than are adults5). TEN is rare disease with incidence of approximately 1.9 cases per million inhabitants annually based on all cases reported to the Food and Drug Administration (FDA) adverse effect reporting system databases in the USA6), and is also rare disease in Korea7). We report a case of TEN in a child that occurred after addition of lamotrigine to the valproic acid treatment, and who was diagnosed clinically and pathologically.
Case report An 11-year-old girl was hospitalized for erythematous maculopapular rash with an
Copyright © 2014 by The Korean Pediatric Society This is an open-access article distributed under the terms of the Creative Commons Attribution NonCommercial License (http://creativecommons.org/ licenses/by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
http://dx.doi.org/10.3345/kjp.2014.57.3.153
153
Yi Y, et al. • Lamotrigine induced toxic epidermal necrolysis
Fig. 1. Diffuse and confluent erythema that covered ≥90% of the total body surface area of the patient on day 1 of hospitalization.
itching sensation over the entire body with fever, conjunctival in jection, eye wax, and oral ulceration. The patient had experience tic disorder since the age of 8 years, and had been diagnosed with major depressive disorder about 7 months previously. The patient was initially treated with fluoxetin, valproate, risperidone, and aripiprazole in psychiatric clinic. However, because of inadequate control, lamotrigine (25 mg/day) was added to the regimen about 3 weeks before hospitalization. After 2 weeks use of lamotrigine, the patient developed an erythematous rash, starting from the face and gradually spreading over the whole body. The patient transfered to Soonchunhyang University Hospital with a diffuse, confluent erythema, which covered over 90% of the total body surface area, conjunctival injection, eye wax, vesicle, and clot on lips and oral ulceration (Fig. 1). The patient also had a fever and skin tenderness, and could not eat properly because of oral pain. During the hospitalization, the skin lesion progressed to a purpuric rash with bullae (Fig. 2). Hemorrhagic crust on the lip was aggravated and Nikolsky’s sign was positive. There was no history of food or drug allergy. Laboratory examination revealed normal complete blood count and serum biochemistry, normal erythrocyte sedimentation rate, and elevated C-reactive protein (7.56 mg/dL). Urinalysis showed pyuria (leukocyte 3+), but urine culture was negative. Chest x-ray was normal. Skin biopsy revealed necrotic keratinocyte in the epidermis with spongiosis and exocytosis, and lymphohistiocytic infiltration in the upper dermis, which suggested TEN (Fig. 3). Consultations with a dermatologist, a plastic surgeon, a psy chiatrist, an ophthalmologist and an otorhinolaryngologist were conducted. We stopped all the psychiatric medications and started intravenous (IV) antibiotics, suspecting secondary infection, in travenous immunoglobulin (IVIG;1.5 gm/kg/day for 3 days)8), and other conservative management including IV hydration, aseptic dressing, topical ointment, nasal irrigation using normal saline, oral humidification, and eye drops. After a week of hospitalization, the skin lesion showed desquamation and was improving (Fig. 4). The tic symptom recurred 2 weeks after we stopped the psychiatric medication, so we used aripiprazole. After
154
http://dx.doi.org/10.3345/kjp.2014.57.3.153
Fig. 2. Generalized dark purpuric erythema with bullae on the trunk.
19 days of hospitalization, the lesion became much improved and the patient was discharged.
Discussion TEN is an unpredictable and severe adverse drug reaction. Although several theories exist, the innate immune system is now favored as a significant contributor to the initiation and propagation of this devastating reaction9). TEN is heralded by the abrupt onset of fever; systemic toxicity; a generalized, dusky, and erythematous rash; bullae; separation of large sheets of epidermis from the dermis; purulent conjunctivitis;
Korean J Pediatr 2014;57(3):153-156
Fig. 3. Histology of the skin biopsy specimen of the patient, showing necrosis of epidermal keratinocytes and lymphocytic infiltration in the upper dermis (H&E, ×200).
Fig. 4. The skin lesion, showing desquamation and improvement.
and mucositis of the mouth and genital area2). In our case, the patient had oral, nasal mucosa and conjunctival involvements along with fever. Complete death of the epidermis leads to sloughing similar to that seen in large burns. TEN includes denudation of >30% of the total body surface area. Stevens-Johnson syndrome (SJS) affects
